subject_line
Save & Return
Use an account to return to saved work.
Log in
Person Served Referral Form
Thank you for considering Philxpry for your new service provider! We review our referrals daily, and carefully assess each and every one to ensure that we are capable of providing the level of care and service that the individual needs. We look forward to reviewing the information below and speaking with you soon.
Person Information
First Name:
*
Middle Initial:
*
Last Name:
*
Date of Birth:
*
+
Gender Identity:
*
Preferred Pronouns:
*
Race:
*
Asian
American Indian or Alaska Native
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other
Other
Services Needed:
*
24-Hour Emergency Assistance
Adult Companion Services
Employment Development Services
Employment Exploration Services
Employment Support Services
Homemaker Services
In-Home Family Support
Individualized Home Support
Individualized Home Support with Family Training
Individiualized Home Support with Training
Respite Care
Child Protection Involvement?:
*
Yes
No
Please indicate the desired number of (weekly) service hours.
*
County of Financial Responsibility:
*
What city does the individual currently live in?:
*
Please provide a copy of the most recent County Support Plan below:
*
Please provide the most recent Diagnostic Assessment below:
*
Education
Is the individual currently enrolled in school?:
*
Yes
No
School Name (If none, N/A):
*
School Setting:
*
In Person
Virtual
Hybrid
Does not attend
Days they attend:
*
Monday
Tuesday
Wednesday
Thursday
Friday
N/A
Times they attend:
*
Full Day
Half Day
N/A
Appointment Consistency Assessment for Families and Individuals.
Can you describe the individual’s or their guardian’s typical behavior regarding attending scheduled appointments on time? Please include any patterns or factors that influence their attendance.
*
In the past 60 days, has the individual or their guardian ever missed an appointment without providing prior notice? If yes, please describe the circumstances and any recurring reasons.
*
How frequently do the individual or their guardian reschedule appointments?
*
Never
Rarely
Occasionally
Frequently
Always
What are the most common reasons given by the individual or guardian for rescheduling or canceling appointments?
*
Health issues
Transportation issues
Forgetfulness
Conflicting commitments
Other
Other
On a scale of 1 to 100, how would you rate the individual’s overall reliability in keeping appointments? (1 being very unreliable and 100 being very reliable)
*
0
100
Social & Medical Information
PMI Number:
*
Allergies, if any:
*
Current Medication List (Please include ALL prescribed medications/PRN's) If none, please enter N/A:
*
Current Diagnosis:
*
Complicating behaviors (If none, please enter N/A):
*
History (Please include relevant family history, medical conditions, and reason for placement):
*
List any upcoming or needed appointments (If none, please enter N/A):
*
Expanded Support Team Information
Under Guardianship?:
*
Yes
No
Legal Guardian/Representative Name:
*
Phone Number:
*
Email Address:
*
Waiver Case Manager Name:
*
Phone Number:
*
Email Address:
*
Mental Health Case Manager Name:
*
Phone Number:
*
Email Address:
*
Do parents have custody?
*
Yes
No
Does the individual have home visits with family/relatives?
*
Yes
No
Thank you for your submission!
If the referral is being sent by e-mail, please use the contact information below:
Connect@philxpry.com
952-999-2897
Please allow at least 3 business days for a response.